Effectiveness of French Physiotherapy in Treating Congenital Clubfoot Deformity

Orthopedics and Rheumatology Open Access Journal

*ANM Muyedul Islam1, Sk Akthar Ahmad2, Md Rashedul Kabir3, Md. Kaoser Bin Siddique4 and Atia Arefin5 1Bangabandhu Sheikh Mujib Medical University, Bangladesh 2Bangladesh Institute of Health Sciences, Bangladesh 3Consultant (Physiotherapy), Jatiya Protibondhi Unnaayan Foundation 4Manager- Research, Evaluation & Development (RED) Department, Lion Mukhlesur Rahman Foundation (LMRF) 5Master of Public Health, North South University Submission: May 08, 2016; Published: May 23, 2016 *Corresponding author: A.N.M. Muyedul Islam, MPhil in Public Health, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh, Tel: 01199074102; Email:

Abstract Clubfoot is the most common congenital structural deformity that leads to physical impairments in children in many developing countries. Neglected clubfoot has been found to be a common cause of physical disability globally among children and young growing adults. The purpose of this study was to investigate the effectiveness of French physiotherapy in treating congenital clubfoot deformity. This cross sectional study was conducted among 102 parents and data were collected by face to face interview with semi-structured questionnaire. Statistical Package for Social Science (SPSS) was used to analyze the data. The mean age of the participants was 405 days. Unilateral limbs were more affected than bilateral limbs. Results shows that out of 30(100%) children with clubfoot deformity, 17(56.7%) were completed cured under French Physiotherapy while 8(26.7%) were completed cured under Ponseti method, almost equal number of children were in both group improved to moderate cured.

the treatment of clubfoot over the Ponseti method. There was significance difference found between two groups after intervention (p<0.05). French physiotherapy was more effective method for Keywords: French Physiotherapy; Congenital Clubfoot

Introduction other conservative method like Ponseti Method. In French method the complication should be minimize. As there no study Disability has emerged as a major public health problem was done in this topic before in our country, I was very much worldwide. Childhood disability is one of them and it remains interested to do research on this topic. hidden in developing country like Bangladesh [1]. Importance of conservative treatment in congenital clubfoot has been Material and Methods known since the Hippocrates era (approximately 400 B.C) [2]. Study design: Randomized clinical trial Continuous passive movement treatment method of French authors has also been added to manipulation, bandage, cast Study population: Children with congenital clubfoot and device applications [3]. There is not a clear opinion in deformity who are attending the selective clinics. the literature on how to treat overcorrection. In the long- Inclusion criteria: term follow-up studies, weakness in muscle groups around the ankle, joint stiffness was found [4,5]. Laaveg & Ponseti [6] a. Willingly participating patients obtained 89% success rate by using the conservative treatment b. Age below 3 years method and minimal invasive surgery if required. Prevalence of congenital clubfoot in Bangladesh is high and most of the c. Before tenotomy patients cases remain untreated or poorly treated [7]. According to Exclusion criteria: French physiotherapy method (93-96%) so congenital clubfoot is manageable if the treatment can be started before child’s 1st a) Benign feet birth day. It is important to identify the effectiveness of French b) Severe clubfoot deformity physiotherapy in treating congenital clubfoot deformity than

Ortho & Rheum Open Access J 2(3): OROAJ.MS.ID.55588 (2016) 001 Orthopedics and Rheumatology Open Access Journal

c) Before treated patient Data collection method Sampling technique questionnaires and in face to face interview. Information about Treatment allocation: Treatment procedure was allocated Data were gathered by pre verified semi structured pregnancy related question, family history & other characteristics randomly in two groups by tossing. The heads were taken in odd serial i.e. group -1 while the tails were placed in even serial i.e. September 2013 at Comilla & Dhaka district. The respondents group 2. was also obtained. The field work was conducted from March to were selected consecutively who will meet the inclusion and Group-1: This group was treated by Ponseti method [8-15]. exclusion criteria. Two interviewers were trained for four days by the author. The training was consisted of lectures on how Group-2: This group was treated by French physiotherapy methods. This treatment will carry out by a team with large participants. experience in managing clubfoot with such a method [16,17]. to fill up the questionnaires and mock interviews between In this study the sample size was taken as 30 for both group i.e Data analysis: Computer technology (SPSS 20.0) version was Ponseti Method and French Physiotherapy Method.

Study place: The study was carried out at- usedThe Piranifor classification, score is a presentationsimple. The andcomponents analysis ofare data. scored as follows: i. BCCW, Dhaka. a. Each component may score 0, 0.5 or 1 ii. NGO- TLMB (Gaibandha), SEID Trust. b. Hind foot contracture score (HCFS): Mid foot contracture Study period and duration: From 14th January 2013 to 13th score (MFCS): January 2014. c. Posterior crease Medial crease Data collection tool and instrument: d. Empty heel Curvature of lateral border A. Face to face interview of mother using pre-tested structure questionnaire e. Rigid equinus Position of head of talus (Table 1). B. Applying both the method by randomizing 60 children

Table 1: Distribution of respondents by demographic characteristics (n=60).

Demographic Ponseti Method Group French Physiotherapy Group Total p-Value Characteristics n (%) n (%) n (%)

Sex of the children

Male 21(70) 21(70) 42(70) 1.00 Female 9(30) 9(30) 18(30)

First visit age in days

0-90 9(30) 8(26.7) 17(28.3)

91-180 4(13.3) 4(13.3) 8(13.3)

181-270 0(0) 1(3.3) 1(1.7)

271-360 2(6.7) 2(6.7) 4(6.7)

361-450 5(16.7) 5(16.7) 10(16.7) 0.991

451-540 3(10.0) 3(10.0) 6(10.0)

541-630 2(6.7) 1(3.3) 3(5.0)

631-720 2(6.7) 3(10.0) 5(8.3)

721-810 3(10.0) 3(10.0) 6(10.0)

How to cite this article: ANM M I, Sk Akthar A, Md Rashedul K, Md. Kaoser B S, Atia A. Effectiveness of French Physiotherapy in Treating Congenital 002 Clubfoot Deformity. Ortho & Rheum Open Access J. 2016; 2(3): 555588. DOI: 10.19080/OROAJ.2016.02.555588 Orthopedics and Rheumatology Open Access Journal

The mean age of the participants was 405 days, n=17 (28%) more common age those who had taken French physiotherapy participants in between 0-90 days of age, n=8 (13%) in between & ponseti method. In control group the participants 21 out of 91-180 days of age and n=1 (2%) in between 181-270 days. n=4 30(70%) were male and 9 out of 30 (30%) were female. Result (7%) participants in between 271-360 days of age, n=10 (17%) shows that male was more affected than female. In intervention in between 361-450 days of age and n=6 (10%) in between 451- group the participants 21 out of 30(70%) were male and 9 out 540 days. n=3 (5%) participants in between 541-630 days of of 30 (30%) were female. Result shows that the male was more age, n=5 (8%) in between 631-720 days of age and n=6 (10%) affected than female (Table 2). in between 721-810 days. Result shows that 0-90 days are

Table 2: Socio-economic characteristics of parents (n=60).

Ponseti Method French Physiotherapy Socio-Economic p-value Group Group Total n (%) Characteristics n (%) n (%) Father Occupation Service 5(16.7) 5(16.7) 10(16.7) Business 13(43.3) 13(43.3) 26(43.3) Farmer 4(13.3) 8(26.7) 12(20.0) 0.569 Day labor 7(23.3) 3(10.0) 10(16.7) Others 1(3.3) 1(3.3) 2(3.3) Father Education illiterate 4(13.3) 6(20.0) 10(16.7) PSC 4(13.3) 5(16.7) 9(15) JSC 9(30.0) 4(13.3) 13(21.7) SSC 4(13.3) 7(23.3) 11(18.3) 0.292 HSC 4(13.3) 6(20.0) 10(16.7) Bachelor 5(16.7) 1(3.3) 6(10.0) Masters 0(0) 1(3.3) 1(1.7) Mother Occupation House maker 29(96.7) 30(100) 59(98.3) 0.313 Day labor 1(3.3) 0(0) 1(1.7) Mother Education Illiterate 6(20.0) 7(23.3) 13(21.7) PSC 6(20.0) 5(16.7) 11(18.3) JSC 14(46.7) 15(50) 29(48.3) 0.982 SSC 3(10.0) 2(6.7) 5(8.3) HSC 1(3.3) 1(3.3) 2(3.3)

In terms of father occupation in ponseti group, out of 30(100%), 5(16.7%) were service holder while the equal number of service holders in French physiotherapy method group, 13(43.3%) were business holders in ponseti group while the equal proportion of respondents were business holders in French physiotherapy method group. Only 13% were farmers in ponseti group whereas the double proportion of fathers were farmers in France physiotherapy method group. Of the fathers in Figure 1: Distribution of respondents by father occupation in ponsity group 23% were day labor while the half of proportion ponseti and French groups (n=60). were day labor in French group. In terms of father education almost equal proportion of fathers was same education level in both groups. Mother occupation indicates that almost all were father were same occupation in ponseti and French group. The The above figure shows that almost equal proportion of house makers in both groups. Educational status was also same majority were involved in business (Table 3). in both groups (Figure 1).

How to cite this article: ANM M I, Sk Akthar A, Md Rashedul K, Md. Kaoser B S, Atia A. Effectiveness of French Physiotherapy in Treating Congenital 003 Clubfoot Deformity. Ortho & Rheum Open Access J. 2016; 2(3): 555588. DOI: 10.19080/OROAJ.2016.02.555588 Orthopedics and Rheumatology Open Access Journal

Table 3: Distribution of the respondents by affected limb (n=60).

Ponseti Method Group French Physiotherapy Group French Physiotherapy Group Subject p-value n (%) n (%) n (%) Right Limb 9(30) 14(46.7) 23(38.3) Affected limb Left Limb 13(43.3) 11(36.7) 24(40) 0.378 Both Limb 8(26.7) 5(16.7) 13(21.7) Results affected & n=24(40%) were left limb affected and bilateral n=13(22%) were involvement of the affected limb of the Result shows that among all the participants in Group A, participants. Result shows that unilateral limbs were more unilateral n=47(78%) among them n=23(38%) were right limb affected than bilateral limbs (Table 4).

Table 4: Distribution of respondents by family history of Clubfoot (n=60).

Family history of Clubfoot Ponseti method French Physiotherapy Total Yes 2(6.7%) 1(3.3%) 3(5.0%) No 28(93.3%) 29(96.7%) 57(95.0%) Result shows that among all the participants approximately in ponseti group and 1(3.3%) were in French Physiotherapy 5% (3 of 60) had past family history of clubfoot and 95% (57 of group (Table 5). 60) had no past family history of club foot. Of them 2(6.7%) were Table 5: Distribution of the respondents by birth history (n=60).

Birth History Ponseti Method n (%) French Physiotherapy n (%) Total n (%) p-value Delivery Time Before 3(10.0) 3(10.0) 6(10.0) 0.838 After 1(3.3) 2(6.7) 3(5.0) In Time 26(86.7) 25(83.3) 51(85) Mode of delivery Normal 18(60) 20(66.7) 38(63.3) 0.592 Cesarean 12(40) 10(33.3) 22(36.7) Problem during pregnancy Yes 0(0) 1(3.3) 1(1.7) 0.313 No 30(100) 29(96.7) 59(98.3) Place of delivery Home 15(50) 17(56.7) 32(53.3) 0.701 Hospital 11(36.7) 8(26.7) 19(31.7) Clinic 4(13.3) 5(16.7) 9(15) Health workers during delivery Yes 16(53.3) 14(46.7) 30(50) 0.606 No 14(46.7) 16(53.3) 30(50) Problem during delivery Yes 0(0) 1(3.3) 1(1.7) 0.161 No 30(100) 29(96.7) 59(98.3) Same Problem in family member Yes 2(6.7) 1(3.3) 3(5.0) 0.554 No 28(93.3) 29(96.7) 57(95.0) Any other disability Yes 1(3.3) 0(0) 1(1.7) 0.313 No 29(96.7) 30(100) 59(98.3)

How to cite this article: ANM M I, Sk Akthar A, Md Rashedul K, Md. Kaoser B S, Atia A. Effectiveness of French Physiotherapy in Treating Congenital 004 Clubfoot Deformity. Ortho & Rheum Open Access J. 2016; 2(3): 555588. DOI: 10.19080/OROAJ.2016.02.555588 Orthopedics and Rheumatology Open Access Journal

In both group 10% baby was preterm while 86% was born in time in ponseti group and 83.3% was in French group, the rest percent. Only 13.3% had clinic in ponseti group and 16.7% in place in delivery was home in both groups. It was about fifty 3.3% in ponseti group and 5% was in France group was born French group. Only 3.3% mothers had suffered problems during in post term. Of the children with clubfoot deformity 60% had delivery while the rest had not suffered any problems during normal mode of delivery in ponseti group while 66.7% had in French group. Cesarean delivery had 40% in ponseti group and during delivery, others had no health workers. Out of 30(100%) delivery. Of the mothers almost fifty percent had health workers 33.3% had in French group. Problem during pregnancy occurred children, only 3.3% had other disability and it was in ponseti 0% in poseti group and 3.3% in French group. Place of delivery group (Table 6). was home, hospital and clinic, the majority of the children’s Table 6: Comparison between Ponseti and French physiotherapy in pre-intervention total score (n=60).

Category Ponseti Method French Physiotherapy Total χ²/Fisher p value Mild deformity (.5-1) 0(0) 0(0) 0(0) Moderate (1.5 -4) 2(6.7) 2(6.7) 4(6.7) 0.000 1.0 deformity Severe deformity (>4) 28(93.3) 28(93.3) 56(93.3) Results shows that out of 60(100%) children with clubfoot deformity equal numbers of them were in both group with severe between two groups before intervention (p>0.05) (Table 7). and moderate deformity. There was no significance difference Table 7: Comparison between Ponseti and French physiotherapy in post-intervention total score (n=60).

Category Ponseti method French Physiotherapy Total χ²/Fisher p value Complete cured 8(26.7) 17(56.7) 25(41.7) Moderate cured 11(36.7) 10(33.3) 21(35.0) 7.859 0.02 Partial cured 11(36.7) 3(10.0) 14(23.3) Results shows that out of 30(100%) children with clubfoot deformity, 17(56.7%) were completed cured under French difference found between two groups after intervention group improved to moderate cured. There was significance Physiotherapy while 8(26.7%) were completed cured under Ponseti method, almost equal number of children were in both the treatment of clubfoot over the Ponseti method (Table 8). (p<0.05). France physiotherapy was more effective method for Table 8: Mean difference between Ponseti and French physiotherapy in post-intervention total score (n=60).

Methods n Mean SD t p Ponseti method 30 1.10 .803 2.947 0.005 French Physiotherapy 30 0.53 0.681 maintenance of movement were recognized [20,21]. Muscular found between two methods in terms of clubfoot treatment weakness and biomechanical changes [22-23], observed in The above table shows that there was significance difference (t=2.9, p=0.005). The calculated mean score was 1.1 and .53 patients who were considered as corrected initially, increased in Ponseti and French physiotherapy method respectively. the popularity of conservative treatment methods again. Cooper French Physiotherapy was more effective treatment for clubfoot & Dietz [24], found functionally and clinically perfect and good deformity. outcomes in 78% of deformities in patients, who were treated by Ponseti, in their average 30 years, follow-up study. This success Discussion rate was 85% in control group, consisting of the patients without The present study showed French physiotherapy was congenital foot deformity. In their magnetic resonance imaging more effective method for the treatment of clubfoot over the study, Pirani et al. [25] detected improvement in both the Ponseti method. A study reporting early results of the Ponseti relation of tarsal bones and the forms of osteochondral outlines treatment, 95% of the deformities were corrected without need of the bones in patients, treated by Ponseti method. These for extensive surgery [18]. This recovery rate is consistent with the results, reported by Herzenberg et al. [19], whose study with a proper treatment method that considers the functional findings support the Ponseti’s hypothesis, which asserts that included similar population and follow-up. Though it was not a anatomy of foot and uses biological potential in the tissues of a new treatment method, Ponseti method had not been adopted newborn, an appropriate improvement can be obtained in most by many and surgical treatment methods had been used as of the deformities which is contradictory with the present study. standard treatment until recent years. Initially, extensive surgical methods aimed physical improvement but owing to long term found between two methods in terms of clubfoot treatment The present study shows that there was significance difference follow-up studies the importance of functional outcomes and (t=2.9, p=0.005). Different conservative treatment methods have

How to cite this article: ANM M I, Sk Akthar A, Md Rashedul K, Md. Kaoser B S, Atia A. Effectiveness of French Physiotherapy in Treating Congenital 005 Clubfoot Deformity. Ortho & Rheum Open Access J. 2016; 2(3): 555588. DOI: 10.19080/OROAJ.2016.02.555588 Orthopedics and Rheumatology Open Access Journal

been suggested in the literature. One of the popular methods in treatment of clubfoot. J Pediatr Orthop B 5(3): 173-180. Europe is the method of Dimeglio et al. [26] consisting of daily 4. Davies TC, Kiefer G, Zernicke RF (2001) Kinematics and kinetics of physiotherapy and continuous passive motion machine. the hip, knee, and ankle of children with clubfoot after posteromedial release. J Pediatr Orthop 21(3): 366-371. With this method, only 28% of the cases required surgical 5. Aronson J, Puskarich CL (1990) Deformity and disability from treated clubfoot. J Pediatr Orthop 10(10): 109-119. and its high cost makes adoption of this method problematic treatment. However, difficulties in long term physiotherapy, 6. Laaveg SJ, Ponseti IV (1980) Long-term results of treatment of in many countries, including our country. In many countries, congenital club foot. J Bone Joint Surg Am 62(1): 23-31. especially in the USA, Kite’s method has been used widely for 7. www.globalclubfoot.org/clubfoot/ Accessed on 02 April 2016. a long time [27]. Kite, who tried to correct the components of the deformity separately and patiently, obtained improvement 8. Ponseti IV (1992) Treatment of congenital club foot. J Bone Joint Surg Am 74(3): 448-454. within 36 weeks. Ponseti attributes such a delay in improvement to the effort for correction of forefoot by counter pressure 9. Coss HS, Hennrikus WL (1996) Parent satisfaction comparing two bandage materials used during serial casting in infants. Foot Ankle Int from calcaneocuboidal joint, which was Kite’s error according 17(8): 483-486. to Ponseti. Because kinematics of the foot does not allow 10. Pittner DE, Klingele KE, Beebe AC (2008) Treatment of clubfoot with evertion of calcaneus before abduction (outward rotation) of the Ponseti method: a comparison of casting materials. J Pediatr it, correction of varus became time consuming for Kite [28]. In Orthop 28(2): 250-253. a careful study, by Tümer et al. [29] where Kite’s and Ponseti’s 11. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, et al. (2004) manipulation methods were used concomitantly, it was reported Factors predictive of outcome after use of the Ponseti method for the that 33% of the cases were treated by only using plaster cast. treatment of idiopathic clubfeet. J Bone Joint Surg Am 86(1): 22-27. This success rate reached at 41% with addition of the patients 12. Gurnett CA, Boehm S, Connolly A, Reimschisel T, Dobbs MB (2008) Impact of congenital talipes equinovarus etiology on treatment that they obtained correction in all of the untreated cases and outcomes. Dev Med Child Neurol 50(7): 498-502. who underwent posterior release surgery. Bursalı [30] reported in 75% of the cases, treated previously elsewhere, by using 13. Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, et al. (2006) Ponseti’s method strictly. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res 451: 171-176. Limitation 14. Barker SL, Lavy CB (2006) Correlation of clinical and ultrasonographic

100% accuracy was not possible in any research so that Surg Br 88(3): 377-379. some limitation may exist. Regarding this study, there were findings after Achilles tenotomy in idiopathic club foot. J Bone Joint 15. Changulani M, Garg NK, Rajagopal TS, Bass A, Nayagam SN, et al. some limitations or barrier to consider the result of the study. (2006) Treatment of idiopathic club foot using the Ponseti method. Initial experience. J Bone Joint Surg Br 88(10): 1385-1387. only 30 samples in each group. A very few researches have been The first limitation of this study was sample size. It was taken 16. Richards B, Wilson H. POSNA (2002) Effect of continuous passive done on a few of research among the effectiveness of French motion in the non-operative treatment of clubfeet: Early results; p. 66. physiotherapy in management of clubfoot patients. So there was 17. Richards BS, Johnston CE, Wilson H (2005) Non-operative clubfoot little evidence to support the result of this project study in the treatment using the French physical therapy method. J Pediatr Orthop context of Bangladesh. 25(1): 98-102. 18. Göksan SB (2002) Treatment of congenital clubfoot with the Ponseti Conclusion method. Acta Orthop Traumatol Turc 36(4): 281-287. This study demonstrates that French physiotherapy method 19. Herzenberg JE, Radler C, Bor N (2002) Ponseti versus traditional is an effective and reproducible method for correction of methods of casting for idiopathic clubfoot. J Pediatr Orthop 22(4): 517-521. idiopathic Congenital Clubfoot deformities. Furthermore, it may be used in our country widely. For successful outcomes, this 20. Hutchins PM, Foster BK, Paterson DC, Cole EA (1985) Long-term results of early surgical release in club feet. J Bone Joint Surg Br 67(5): technique should be applied carefully and the patients should 791-799. use the foot abduction orthosis with full compliance. For patient 21. Catterall A (2002) Early assessment and management of the club foot. compliance, besides parent training, producing proper and In: Benson MK, Fixsen JA, et al. (Eds), Children’s orthopaedics and comfortable shoes is required. fractures (2nd edn), London: Churchill Livingstone pp. 464-477. References 22. Davies TC, Kiefer G, Zernicke RF (2001) Kinematics and kinetics of the hip, knee, and ankle of children with clubfoot after posteromedial 1. Shawky S, Abalkhail B, Soliman N (2002) An epidemiological study release. J Pediatr Orthop 21(3): 366-371. of childhood disability in Jeddah, Saudi Arabia. Paediatr Perinat Epidemiol 16(1): 61-66. 23. Aronson J, Puskarich CL (1990) Deformity and disability from treated clubfoot. J Pediatr Orthop 10(1): 109-119. 2. Translated by Adams F. Hippocrates. On the articulations. [87 screens]. 24. Cooper DM, Dietz FR (1995) Treatment of idiopathic clubfoot. A thirty- 3. Diméglio A, Bonnet F, Mazeau P, De Rosa V (1996) Orthopaedic year follow-up note. J Bone Joint Surg Am 77(10): 1477-1489. treatment and passive motion machine: consequences for the surgical

How to cite this article: ANM M I, Sk Akthar A, Md Rashedul K, Md. Kaoser B S, Atia A. Effectiveness of French Physiotherapy in Treating Congenital 006 Clubfoot Deformity. Ortho & Rheum Open Access J. 2016; 2(3): 555588. DOI: 10.19080/OROAJ.2016.02.555588 Orthopedics and Rheumatology Open Access Journal

25. Pirani S, Zeznik L, Hodges D (2001) Magnetic resonance imaging study 29. Tümer Y, Bi of the congenital clubfoot treated with the Ponseti method. J Pediatr ekinovarus’un konservatif tedavisi. Acta Orthop Traumatol Turc 16: Orthop 21(6): 719-726. 148-59. çimoğlu A, Açıkgöz T, Dinçer D (1982) Doğuştan pes 26. Diméglio A, Bonnet F, Mazeau P, De Rosa V (1996) Orthopaedic 30. treatment and passive motion machine: Consequences for the surgical treatment of clubfoot. J Pediatr Orthop B 5(3): 173-80. Bursalı A (2001) Pes ekino varus (PEV) tedavisinde Ponseti metodunun Türkiye.erken sonuçları. 2001. In: Alpaslan AM, (Eds), XVII. Ulusal Ortopedi ve 27. Kite JH (1972) Nonoperative treatment of congenital clubfoot. Clin Travmatoloji Kongresi Kongre Kitabı; 24-29 Ekim 2001; Antalya, Orthop Relat Res 84: 29-38. İstanbul: Turgut Yayıncılık; pp. 338-339. 28. Cooper DM, Dietz FR (1995) Treatment of idiopathic clubfoot. A thirty- year follow-up note. J Bone Joint Surg Am 77(10): 1477-1489.

How to cite this article: ANM M I, Sk Akthar A, Md Rashedul K, Md. Kaoser B S, Atia A. Effectiveness of French Physiotherapy in Treating Congenital 007 Clubfoot Deformity. Ortho & Rheum Open Access J. 2016; 2(3): 555588. DOI: 10.19080/OROAJ.2016.02.555588